Columbus, OH - January 2016
Neonatologists often struggle with the timing of extubation. Although prolonged mechanical ventilation in premature infants is linked to the development of bronchopulmonary dysplasia (BPD), there has been considerable debate as to whether extubating too early may also cause its own set of issues.
A recent study from Nationwide Children’s Hospital, however, demonstrates that when efforts are made to extubate as soon as possible, premature infants are less likely to develop BPD and spend less time in the hospital.
“It’s hard to extubate a tiny baby quickly. You worry that if it fails, it could create more problems than if you hadn’t done it,” says Edward Shepherd, MD, chief of the Section of Neonatology at Nationwide Children’s and senior author of the study. “This is a nice reassurance that even if it fails, it’s a good thing to do. Those kids with failed extubation attempts still did better than kids who weren’t attempted.”
The study, published in the Journal of Neonatal-Perinatal Medicine, assessed the medical records of 224 infants born at less than 27 weeks gestational age and referred to the small baby neonatal intensive care unit at Nationwide Children’s. The decisions to extubate and reintubate were driven by the care team, not by established protocol, although clinical guidelines were in place.
Researchers found that day of life at the first extubation attempt was positively correlated with length of time on mechanical ventilation – that is, infants who were younger at initial extubation spent less time on a ventilator. This finding did not vary even though 64 percent of infants had to be reintubated after extubation.
The day of life of first extubation attempt also positively correlated with the discharge day of life. Linear regression models predicted that for every day that the first extubation attempt is delayed, nearly another day of hospitalization is incurred. From a cost perspective, every day the first extubation attempt is delayed is $4,555 in extra hospital charges.
There was also an association between early initial attempts and decreased need for supplemental oxygen at 28 days of life and 36 weeks post-menstrual age, as well as reduced requirements for intermittent positive pressure intervention and nasal continuous positive airway pressure at 36 weeks. All of these findings suggest that the older the infant at first extubation attempt, the more likely the patient will have moderate-to-severe BPD.
On the other hand, reintubation was not associated with mortality, moderate-to-severe BPD or length of stay. The study has reinforced Nationwide Children’s institution of protocols that encourage neonatology staff members to extubate more rapidly, says Dr. Shepherd.
“The findings mean we need to begin planning to extubate these infants on the first day they arrive here,” says Dr. Shepherd, who is also an associate professor of Clinical Pediatrics at The Ohio State University College of Medicine. “We focus on and prioritize extubation.”
Robbins M, Trittmann J, Martin E, Reber KM, Nelin L, Shepherd E. Early extubation attempts reduce length of stay in extremely preterm infants even if re-intubation is necessary. Journal of Neonatal-Perinatal Medicine. 2015 Jul 31;8(2):91-7.